This document discusses the importance of documentation in healthcare. It covers why, when, how, who, and where documentation should occur. Documentation fosters quality care, continuity of care for patients, and effective communication between providers. It also establishes a legal record in case of lawsuits. The document emphasizes that documentation should occur at every point of contact with the patient using methods like SOAP notes. Proper documentation includes legible writing, signatures, and noting both positive and negative exam findings. Lack of documentation can result in legal penalties if complications occur but actions were not documented. Informed consent is also crucial and must be properly documented.

1. DOCUMENTATION –
IN HEALTHCARE
Topics covered:
* WHY
* WHEN
* HOW
* WHO
* WHERE
Speaker:
Dr. Sushmita Biswas
MBBS-DLO-MBA(HEALTHCARE)

4. • Fosters quality and continuity of care to the
patient
• Establishes an effective communication amongst
the healthcare providers
• Its speaks much louder than our vocal cords, and
it speaks for years till the document is preserved
• Serves as an evidence in the court of LAW

5. MANY PHYSICIANS COMPLAIN THAT THEY
DO NOT HAVE THE TIME TO WRITE NOTES.
“WOULD YOU RATHER SPEND THE TIME IN
COURT FOR 12 WEEKS, 5 DAYS A WEEK, FROM
9AM TO 5 PM?”
Boschert, Sherry ; Documentation do’s and dont’s can derail a lawsuit, 2005, OB/GYN News

6. AT THE FIRST POINT OF CONTACT
&
AT EVERY POINT OF CONTACT

7. SOAP Notes
New SOOOAAP notes

8. S SUBJECTIVE
• Chief complaints
• H/O present illness
• Past illness
• Drug history +/- allergy
• Medical history/Co-morbidities
• Family history
• Addictions
O OBJECTIVE
• Vital signs
• General examination
• Local examination(if any)
• Systemic examination- all four
systems
A ASSESSMENT
Provisional Diagnosis
Differential Diagnosis
Final Diagnosis
P PLAN
• Investigations
• Monitoring instructions
• Medicines
• Patient/relatives
communication &
education
• Follow ups

9. S- Subjective
O- Objective
O- Opinion
O- Options
A- Advice
A- Agreed plan

10. Time and Date your( with name in
BLOCK LETTERS & signature) entries
LEGIBLE WRITING
Destroy evidence
Mention significant positive & negative
entries : History & Examination
Change records: sophisticated technology
can detect alteration of records
Label any addition as “ Late Entry” Peer review comments
DO’s DON’T’s

11. A surgeon was held to be
guilty of negligence for
conducting sterilization
operation during caesarian
without obtaining consent.
A gynecologist has been
sued heavily as she was
found guilty of performing
abdominal hysterectomy
instead of vaginal
hysterectomy.
Wrong site,
Wrong side,
Wrong person
The court has
held a consent
given for excision
biopsy, cannot
by inference be
taken as implied
consent for
surgery
Case of
Negligence:
Tumour
mistaken for
fetus
Failure to
document non-
compliance &
lack of informed
refusal : physician
is considered
guilty

12. A senior colleague
documented as “ovarian
cyst” was fabricated as
“twisted ovarian cyst”
by a junior colleague
and opened the
abdomen to find a fetus
of 28 weeks gestational
age.
This case was a near
miss from the blind eyes
of the Judicial lady.
Allegations & trial set in for
FAILURE OF DIAGNOSIS OF
HERPES SIMPLEX VIRUS,
IMPROPER PRESCRIPTION OF
TOPICAL STEROID leading to
Keratitis…called for a
penalty of 25 lacs to the
treating physician.
A male patient after a
successful revival Post
CPR, the patient sued
against the hospital for
giving him two huge
scars on his chest,
because the paddles w
ere not jellied.
Penalty of 25 Lacs on
the hospital in 2004.

13. INFORMED CONSENT:
• To be taken and signed by the
SURGEON herself/himself
• From the patient (Exceptions:in
cases of mental disorder or minor
or comatose)
• A consent which is not properly
informed is vulnerable for law suits
( ie expected complications or
expected change of plan in surgery
should be informed &
documented).

14. Failed consent in cases of emergency or
unconsciousness :
* all considerations regarding consent will be set
aside to save the life of a patient, to save him from
permanent disability or/ and suffering.
* should be countersigned by board of 3 people in
life saving procedures.

15. Informed Consent is mandatory before:
* Any invasive (major/minor)
procedure/activity
* Blood Transfusion
* Restraint consent
* Pre-operative & pre- anaesthetic consent
* Intra-operative change in plan needs a
formal consent

22. If it is NOT documented Then it is NOT DONE
If it cannot be Understood Then it DID NOT HAPPEN
If it cannot be read Then it DID NOT HAPPEN
& If it DID NOT HAPPEN Then it should NOT BE PAID
If there is ANY complication because
either appropriate action not taken
or not documented
Vulnerable for LEGAL PUNISHMENTS